Agency medic failed to spot ‘heart attack’

A DONCASTER office manager died after a foreign locum doctor who had received no induction or training by the NHS failed to notice her serious heart problem.

The family of Irene Mitchell are furious that the agency medic failed to spot what they described as a heart attack, and sent her home after she had gone to Doncaster Royal Infirmary for help.

Irene, a 59-year-old grandmother from Conisbrough, who was manager of Mark Jarvis bookies in Denaby, arrived at hospital with severe chest pains.

But Dr Ali Mehri failed to read the results of an ECG correctly and sent her home without treatment on December 17, 2009.

As her condition deteriorated the mum-of-two returned to the hospital again for help three days later.

She was not transferred to the coronary care unit for surgery at the Northern General in Sheffield until two days later, and died on Christmas Day before the surgery could be performed.

A narrative verdict was recorded by Doncaster coroner Nicola Mundy at an inquest, with Ms Mundy saying failure to act upon the ECG and administer urgent treatment had contributed towards Irene’s death.

Following the hearing, the family said although nothing will ever bring her back they are relieved to have some answers so they can begin to try to move on.

Irene’s daughter Sadie Daines said she was concerned an agency doctor without NHS training had been in charge.

She said: “Our anger is never going to go away. We are still angry that this was allowed to happen. This man was the senior person that day and she was sent home.

“We want people to challenge what doctors say. We asked for her not to be sent home, but that is what happened.”

Irene’s husband Melvin Mitchell said: “She did not receive the care she needed because of avoidable errors which led to her being discharged home instead of being admitted.

“We kept telling hospital staff that she was seriously ill but were repeatedly reassured.”

The family’s lawyer, Beth Reay, from Irwin Mitchell, said Doncaster and Bassetlaw Hospitals NHS Foundation Trust had recognised failures involved in Irene’s case and apologised to the family.

She said: “The failure to read the results of Irene’s ECG test in this case led to a lengthy delay in diagnosis and by the time her cardiac problems were eventually recognised the opportunity to give her drug treatment, which may have saved her life, had been missed.

“Although we welcome the changes the Trust has made at Doncaster Royal Infirmary since Irene’s death, and the apology made to the family, the Mitchells want assurances that lessons learnt will be shared throughout the NHS to prevent any other family from suffering.”

Dr Mehri had received no induction or training when he arrived at the trust, having previously worked in Qatar. He was recruited via an agency just three weeks before Irene’s death.

The coroner heard existing staff had raised questions about his clinical methods and the standard and speed of his work. Despite concerns, he was one of the most senior doctors in the accident and emergency department.

A statement from the Doncaster and Bassetlaw Hospitals NHS Foundation Trust said: “The inquest into Mrs Mitchell’s death found she had died from the effects of coronary artery atheroma. But the coroner also indicated that, had the abnormal ECG on December 17, 2009, been acted upon, Mrs Mitchell’s life would have been prolonged and she would on balance not have died when she did. We have accepted that verdict and have apologised to the family.

“Dr Ali Mehri started work at DRI on November 23, 2009, coming from a specialist agency. Excellent references were received that put him well within the capabilities of a staff grade role, and able to work without direct supervision.

“Events surrounding this case were investigated in line with NHS Clinical Governance arrangements. The conclusions were shared with the family and an apology from the Trust was given.”